Healthcare providers in the United States are required to use CPT and ICD-9 codes to provide information to payers and government entities. CPT stands for Current Procedural Terminology and ICD-9 stands for the International Classification of Disease 9th Revision. ICD-10 is coming in October, 2013, and will be radically different. More will come out on that since we don’t want to be teaching this too soon because YOU WILL FORGET IT ALL BY 10/2013! As a certified professional coder, I am interested in the details and minutiae of coding. Most providers are not, so here is a summary of one of the more common problems in a healthcare practice.

This consultation is not about the specific details of CPT and ICD-9, but more about how they relate to each other. How they “match up” is critical for timely reimbursement and insuring you are compliant and being protected during a retrospective review. One very simple example is ensuring any area of the spine that you are treating has been examined and has a proper ICD-9 diagnosis. CPT coding must match your ICD-9 diagnosis. Basically, the procedures that you are performing can only be on areas that were diagnosed to have a problem that you are treating. Let me give you an example that is pertinent to the chiropractic office.

Diagnosis - 722.0, 723.1, 739.1, 739.2, 728.5 There are a few things here. First, although the CMS-1500 [HCFA] only allows for 4 codes, your documentation MUST include all relevant diagnosis codes and in many cases there are more than 4. When you provide treatment to this area, using the codes for chiropractic spinal manipulation, we know that they are organized according to spinal areas. Cervical (including the atlanto-occiptal joint), thoracic (including costochondral and costotransverse joints), lumbar, pelvic and sacral regions. The 5 extraspinal regions are head (including tempormandibular joint, excluding atlanto-occipital), lower extremities, upper extremities, rib cage (excluding costochondral and costotransverse joints) and abdomen. The CPT codes are as follows:

98940 - Chiropractic Manipulative Treatment 1-2 spinal regions

98941 - Chiropractic Manipulative Treatment 3-4 spinal regions

98942 - Chiropractic Manipulative Treatment 5 spinal regions

98943 - Chiropractic Manipulative Treatment extraspinal

There MUST be a diagnosis code for EACH spinal area that you are including in the above CPT codes. The above codes include cervical spine diagnosis (722.0, 723.1, 739.1 and 728.85) and a thoracic spine code (739.2).In this case, using CPT code 98941 would be considered fraudulent since there are only 2 regions diagnosed. There is no justification for the 3rd or 4th region in the billing. That is what cross coding is all about. One has to “jive” with the other.

Let’s say that you did diagnose and treat 3 regions, but put the codes in this order: 722.0, 723.1, 739.1, 739.2, 728.5, 722.10.The extra code is 722.10which is a code for lumbar disc herniation, but in this sequence, it is the 6th code! That is the third region. HOWEVER, if you remembered that the CMS-1500 has only FOUR spaces for ICD-9 codes, you would only be reporting the cervical and thoracic codes to the carrier, 722.0, 723.1, 739.1, 739.2, while you were billing the 98941CPT code. When the carrier reviewed your CMS-1500, what would they see? They would only see 2 regions! Therefore, to remedy that, we would put in the primary code for each spinal region if there were more than 4 ICD-9 codes, so your CMS-1500 diagnosis would look like this…722.0, 723.1, 739.1, 722.10and in your notes the codes would look like 722.0, 739.2, 722.10, 723.1, 739.1, 728.85AND you would send in your office notes for the visits being billed on the CMS-1500. The primary code for the cervical spine is 722.0, the primary for the thoracic spine is 739.2, the primary for the lumbar spine is 722.10 and then the rest follow in no particular order.